CareSource Marketplace Standard Silver Dental, Vision, & Fitness - 50328WV0020023 Health Insurance Plan
CareSource West Virginia Co. health insurance plan with the Plan ID 50328WV0020023. The plan is called CareSource Marketplace Standard Silver Dental, Vision, & Fitness.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 100.00% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 0.00% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
| Health Insurance Plan ID | 50328WV0020023 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | West Virginia | ||||||||||||||||||
| Health Insurance Issuer | CareSource West Virginia Co. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 50328WV0020023-02 | ||||||||||||||||||
| Provider Network(s) | ['WVN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 23 Apr 2024 07:07 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 50328WV0020023-00 Standard On Exchange Plan - 50328WV0020023-01 Open to Indians below 300% FPL - 50328WV0020023-02 Open to Indians above 300% FPL - 50328WV0020023-03 73% AV Silver Plan - 50328WV0020023-04 |
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| Last Plan Update Date | Thu, 18 Aug 2022 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 23 Apr 2024 07:07 GMT |
Benefits of CareSource Marketplace Standard Silver Dental, Vision, & Fitness Health Insurance Plan, 50328WV0020023-02
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | $0.00, 0.00% |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $0.00, 0.00% |
100.00% |
| Bariatric Surgery
Surgery determined to be Medically Necessary is Covered |
YES | $0.00, 0.00% |
100.00% |
| Basic Dental Care - Adult
$1,000 Annual limit combined for all Adult Dental Services. See plan documents for details on benefit limits |
YES | $0.00, 0.00% |
100.00% |
| Basic Dental Care - Child
See plan documents for details on benefit limits |
YES | $0.00, 0.00% |
100.00% |
| Chemotherapy
|
YES | $0.00, 0.00% |
100.00% |
| Chiropractic Care
Limit: 30.0 Visit(s) per Year |
YES | $0.00, 0.00% |
100.00% |
| Chronic Pain Treatment
Limit: 20.0 Visit(s) per Episode Physical Therapy, Occupational Therapy, Osteopathic Manipulation, a Chronic Pain Management Program, and Chiropractic Services limited to 20 combined visits per event. Separate limits from Rehabilitative and Habilitative services. |
YES | $0.00, 0.00% |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | $0.00, 0.00% |
100.00% |
| Dental Check-Up for Children
Limit: 2.0 Visit(s) per Year |
YES | $0.00, 0.00% |
100.00% |
| Diabetes Education
|
YES | $0.00, 0.00% |
100.00% |
| Dialysis
|
YES | $0.00, 0.00% |
100.00% |
| Durable Medical Equipment
|
YES | $0.00, 0.00% |
100.00% |
| Emergency Room Services
Emergency room copay or coinsurance is waived if you are admitted to the hospital directly from the Emergency Department. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Emergency Transportation/Ambulance
Ambulance transports must be made to the closest local facility that can provide you with covered services appropriate for your medical condition. |
YES | $0.00, 0.00% |
0.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Limited to one pair of glasses or contact lenses per benefit year. |
YES | $0.00, 0.00% |
100.00% |
| Gender Affirming Care
Surgery determined to be Medically Necessary is Covered |
YES | $0.00, 0.00% |
100.00% |
| Generic Drugs
|
YES | $0.00, 0.00% |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Year Physical Therapy & Occupational Therapy limited to 30 visits each per benefit period.? Autism Spectrum Disorder Services with limits combined with Habilitative Services. |
YES | $0.00, 0.00% |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 100.0 Visit(s) per Year A visit equals at least 4 hours |
YES | $0.00, 0.00% |
100.00% |
| Hospice Services
Must have a terminal illness with life expectancy of 6 months or less. |
YES | $0.00, 0.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | $0.00, 0.00% |
100.00% |
| Infertility Treatment
Exclusions: The diagnosis and treatment of underlying medical causes of infertility are generally covered, however infertility treatments, such as artificial insemination/invitro fertilization, are not covered. |
YES | $0.00, 0.00% |
100.00% |
| Infusion Therapy
|
YES | $0.00, 0.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | $0.00, 0.00% |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | $0.00, 0.00% |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | $0.00, 0.00% |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
$1,000 Annual limit combined for all Adult Dental Services. See plan documents for details on benefit limits. |
YES | $0.00, 0.00% |
100.00% |
| Major Dental Care - Child
See plan documents for details on benefit limits |
YES | $0.00, 0.00% |
100.00% |
| Mental/Behavioral Health Inpatient Services
|
YES | $0.00, 0.00% |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $0.00, 0.00% |
100.00% |
| Non-Preferred Brand Drugs
|
YES | $0.00, 0.00% |
100.00% |
| Nutritional Counseling
Diet education covered in the context of diabetes self-management education. |
YES | $0.00, 0.00% |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Limited to Medically Necessary Orthodontia. See plan documents for details on benefit limits. |
YES | $0.00, 0.00% |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $0.00, 0.00% |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $0.00, 0.00% |
100.00% |
| Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Year Physical Therapy, Occupational Therapy, and Pulmonary Rehabilitation limited to 30 visits each per benefit period.? Cardiac Rehabilitation limited to 36 visits per benefit period. |
YES | $0.00, 0.00% |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | $0.00, 0.00% |
100.00% |
| Preferred Brand Drugs
|
YES | $0.00, 0.00% |
100.00% |
| Prenatal and Postnatal Care
|
YES | $0.00, 0.00% |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | $0.00, 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $0.00, 0.00% |
100.00% |
| Private-Duty Nursing
Limit: 35.0 Visit(s) per Year A visit equals 8 hours or less. |
YES | $0.00, 0.00% |
100.00% |
| Prosthetic Devices
|
YES | $0.00, 0.00% |
100.00% |
| Radiation
|
YES | $0.00, 0.00% |
100.00% |
| Reconstructive Surgery
Benefits include reconstructive surgery to correct significant deformities caused by congenital or developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal appearance. Benefits include surgery performed to restore symmetry after a mastectomy. |
YES | $0.00, 0.00% |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year 30 visit each for Occupational and Physical Therapies. |
YES | $0.00, 0.00% |
100.00% |
| Rehabilitative Speech Therapy
|
YES | $0.00, 0.00% |
100.00% |
| Routine Dental Services (Adult)
Limit: 2.0 Visit(s) per Year $1,000 Annual limit combined for all Adult Dental Services. See plan documents for details on benefit limits |
YES | $0.00, 0.00% |
100.00% |
| Routine Eye Exam (Adult)
|
YES | $0.00, 0.00% |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year |
YES | $0.00, 0.00% |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
|
YES | $0.00, 0.00% |
100.00% |
| Specialist Visit
|
YES | $0.00, 0.00% |
100.00% |
| Specialty Drugs
|
YES | $0.00, 0.00% |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | $0.00, 0.00% |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $0.00, 0.00% |
100.00% |
| Transplant
Quantitative limit units apply, see Summary of Benefits and Coverage. |
YES | $0.00, 0.00% |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | $0.00, 0.00% |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | $0.00, 0.00% |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | $0.00, 0.00% |
100.00% |
CareSource Marketplace Standard Silver Zero Dental, Vision, & Fitness Health Insurance Plan Variant 50328WV0020023-02 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 1 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2023 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Zero Cost Sharing Plan Variation |
| Dental Only Plan | No |
| Design Type | Design 1 |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy |
| EHB Percent of Total Premium | 0.990589401 |
| First Tier Utilization | 100% |
| Formulary ID | WVF005 |
| Formulary URL | URL |
| HIOS Product ID | 50328WV002 |
| Import Date | 8/18/2022 20:01 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | Yes |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 50328 |
| Issuer Marketplace Marketing Name | CareSource |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Silver |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | WVN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Services Only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency Services Only |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 50328WV0020023-02 |
| Plan Marketing Name | CareSource Marketplace Standard Silver Dental, Vision, & Fitness |
| Plan Type | HMO |
| Plan Variant Marketing Name | CareSource Marketplace Standard Silver Zero Dental, Vision, & Fitness |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | WVS001 |
| Source Name | SERFF |
| Plan ID | 50328WV0020023 |
| State Code | WV |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $0 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $0 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $0 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $0 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $0 |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of CareSource Marketplace Standard Silver Dental, Vision, & Fitness Health Insurance Plan, 50328WV0020023
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about CareSource Marketplace Standard Silver Dental, Vision, & Fitness, 50328WV0020023 Health Insurance Plan, 50328WV0020023
-
Does CareSource Marketplace Standard Silver Dental, Vision, & Fitness Health Insurance Plan, 50328WV0020023 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (50328WV0020023) Health Insurance Plan, Variant (50328WV0020023-02) offer Disease Management Programs?
Does (50328WV0020023) Health Insurance Plan, Variant (50328WV0020023-02) have Out Of Country Coverage?
Does (50328WV0020023) Health Insurance Plan, Variant (50328WV0020023-02) have Out of Service Area Coverage?
Does (50328WV0020023) Health Insurance Plan, Variant (50328WV0020023-02) offer Disease Management Programs?
Does CareSource Marketplace Standard Silver Zero Dental, Vision, & Fitness Health Insurance Plan, Variant (50328WV0020023-02) offer Disease Management Programs for Asthma?
Does CareSource Marketplace Standard Silver Zero Dental, Vision, & Fitness Health Insurance Plan, Variant (50328WV0020023-02) offer Disease Management Programs for Heart disease?
Does CareSource Marketplace Standard Silver Zero Dental, Vision, & Fitness Health Insurance Plan, Variant (50328WV0020023-02) offer Disease Management Programs for Depression?
Does CareSource Marketplace Standard Silver Zero Dental, Vision, & Fitness Health Insurance Plan, Variant (50328WV0020023-02) offer Disease Management Programs for Diabetes?
Does CareSource Marketplace Standard Silver Zero Dental, Vision, & Fitness Health Insurance Plan, Variant (50328WV0020023-02) offer Disease Management Programs for High blood pressure & high cholesterol?
Does CareSource Marketplace Standard Silver Zero Dental, Vision, & Fitness Health Insurance Plan, Variant (50328WV0020023-02) offer Disease Management Programs for Low back pain?
Does CareSource Marketplace Standard Silver Zero Dental, Vision, & Fitness Health Insurance Plan, Variant (50328WV0020023-02) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 23 Apr 2024 07:07 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API